The Coming Doctor Shortage

Let’s say it all works out and we welcome the supposed 45 million or so individuals without healthcare insurance into the fold and they receive the preventive care and primary care that we are told will solve the problems of American healthcare. Based on the assumption that these uninsured people are not receiving healthcare now, we will need about 100,000 more doctors than we have at present (our current physician workforce is about 900,000 physicians). This number is based on our current count of 2.43/1000 population according to the Organization for Economic Cooperation and Development. Let’s be conservative and assume that half of these individuals are receiving some kind of care now, so that we will only need 50,000.

One response to this assumption may be that we already have too many doctors. Perhaps, but the average in the much-admired France, for example, is about 30% higher per 1000 population than in the U.S., so it is likely that we will really need at least that many more doctors to handle the workload.

The reasons for the shortage of physicians in the U.S. are quite complex and, as usual, there is a component of blame attributable to Congress and Medicare.

In order to secure a medical license, one needs to graduate from an accredited medical school and then take at least a one year postgraduate residency position, although the vast majority of graduates, even those entering primary care type practices, pursue an additional 2 to 3 years of training. For some specialties of surgery or medicine, the additional post-graduate training can be 5 to 8 years.

Medicare is the largest single source of funding of graduate medical education, another name for residency training.  The Department of Veterans Affairs also finances the training of about 10% of residents. The costs of graduate medical education are financed by Medicare under two mechanisms: Direct Medical-Education payments to hospitals for a share of residents’ stipends, faculty salaries, administrative expenses, and an overhead allocation to residency programs; and the so-called Indirect Medical-Education adjustment to Medicare payments for each Medicare patient treated at the hospital. The rationale for this indirect education adjustment is the relatively higher costs attributable to the more severe degrees of illness typical of Medicare patients who require specialized services available in teaching hospitals.

In 1997, Medicare’s direct payments for graduate medical education totaled $2.2 billion — 47 percent more than in 1990. Medicare’s indirect medical-education adjustment is based on the number of full-time-equivalent residents who are being trained in the inpatient and outpatient departments of a teaching hospital. Generally, the more residents there are, the greater the payments to a hospital will be. Such payments to teaching hospitals totaled $4.6 billion in 1997 — 84 percent more than in 1990.

In an effort to cut the costs of Medicare, the Balanced Budget Act of 1997 was enacted. Among other effects, it reduced direct payments for Graduate Medical Education by $700 million and trimmed $1.1 billion per year off Medicare’s indirect teaching payments for the subsequent five years. Also, for the first time, Congress imposed a cap on the number of residents the program would support by its direct and indirect teaching payments. The idea was that fewer physicians would mean lower costs.

The impetus to the reduction was, in part, a report by the Institute of Medicine, a prestigious government think tank as an arm of the National Academy of Sciences, that stated, “The Institute of Medicine committee recommends that:

• No new schools of allopathic or osteopathic medicine be opened, that class sizes in existing schools not be increased, and that public funds not be made available to open new schools or expand class size.
• The federal government reform policies relating to the funding of graduate medical education, with the aim of bringing support for the total number of first-year residency slots much closer to the current number of graduates of U.S. medical schools.” (Since a large number of new physicians each year are international medical graduates, this proposal represented a huge potential reduction, some 25%)

This was a disastrous error as we now face the aforementioned shortfall in primary care physicians for the proposed newly insured individuals in addition to a universally recognized coming shortage of all types of physicians, both primary care and specialist physicians. In proof, the new 2008 recommendation made by the governing body of the nation’s medical schools (the Association of American Medical Colleges) demands that,” serious efforts must be made to expand the number of health professionals educated to care for a population that continues to grow and whose aging will place unprecedented demands upon the health care system.”

So much for central planning. (See Soviet Union, 1967)

Since it takes 10 years to even begin to expand the pool of American physicians, the misjudgment in 1996 means that we will not even begin to see increased numbers of trained physicians until 2019 at the earliest.

But do not fear. Congress has reacted. We will be able to “recruit” more international medical graduates. In May 2009, Senator Bill Nelson (D-FL) introduced the Resident Physician Shortage Reduction Act of 2009 in the Senate, and Representative Joseph Crowley (D-NY) introduced identical legislation in the House of Representatives. This bill proposes to increase the number of Medicare-supported residency positions across the United States by 15%, or approximately 15,000 positions. The bill also proposes changes in the distribution of currently available positions and encourages the creation of new positions in primary care and general surgery programs.  This program will help correct some maldistribution of positions but mostly it will allow more international medical graduates to earn the right to practice medicine in the United States, as primary care physicians. This is the only type of medical practice that allows foreigners to avoid a 2 year return to their home country prior to qualifying for US work visas.

So in the end, it is possible through mass migration of international medical graduates, creation of increased training positions, and the construction of new medical schools, that by 2020 or so, we will have more primary care physicians. This will certainly help with prevention, screening for disease, and management of routine and most non-life threatening conditions. However, if you need your prostate removed by the latest robotic and tissue sparing technology or you develop a malignancy that requires complex surgery, radiation therapy, and chemotherapy, beware. Another face of rationing is the inability to find a medical or surgical specialist to manage those sorts of life-threatening illnesses. For example, two independent studies have reported that there will be a 50% increase in the demand for the services of cancer specialists over the next decade and that was before any notion of health insurance reform. This will greatly outstrip the supply of cancer specialists given the current number of  approved training positions.

If the argument for a wholesale revamping of American healthcare depends on the large number of uninsured, typically estimated at 45 million (although a New York Times editorial elevated the number of medically uninsured and underinsured to over 100 million), then there had better be some plan that goes along with the reform to find the 25,000 to 50,000 new physicians that will be required. And by the way, since the number of physicians retiring in the next decade will be about 25,000 per year, you can see we have a bit of a problem.

A little preview of physician availability from Massachusetts healthcare reform via the New York Times:

Dr. Patricia A. Sereno, state president of the American Academy of Family Physicians, said an influx of the newly insured to her practice in Malden, just north of Boston, had stretched her daily caseload to as many as 22 to 25 patients, from 18 to 20 a year ago. To fit them in, Dr. Sereno limits the number of 45-minute physicals she schedules each day, thereby doubling the wait for an exam to three months.

“It’s a recipe for disaster,” Dr. Sereno said. “It’s great that people have access to health care, but now we’ve got to find a way to give them access to preventive services. The point of this legislation was not to get people episodic care.”